Musings of a Distractible Mind

Being a doctor involves hearing a person's narrative and working to direct it in the best direction possible. There are some people for whom I have become a significant part of their narrative, and others whose narrative I know better than anyone else. It's a bond that doesn't happen anywhere else.

So much bad stuff is (justifiably) said about the healthcare system, and how it is becoming distant, frustrating, impersonal, and dehumanized. That is certainly true in many settings, as we value data, documentation, diagnosis codes, and checklists over the humans for which it's supposedly built. My office is a sanctuary for me, my staff, and my patients from that impersonal world. But the time I spent in the ICU encouraged me greatly, as I saw that people there, in the middle of one of the most stressful settings in my profession, are still caring. They are caring about the work they do, caring about their patients, caring about the families, and caring about doing what is right. In the midst of the hectic world of the ICU, they took the time to talk to me even though I was not at all involved in the patient's care.

My in-laws are in town for my daughter's graduation. When I came home yesterday I was greeted with a big smile and vigorous handshake from my father-in-law. "I just want to thank you," he said, standing up from his chair, "for finding us a good doctor. The one you found for us is wonderful."

My wife smiled at me warmly. I just earned myself big points. Yay!

Her parents and mine are both in their 80's and are overall in remarkably good health. When I called my father after he had a minor surgery over the summer, my mother told me he had a ladder and was "on a bee hunt." It's a blessing to have them around, especially having them healthy.

My parents have a wonderful primary care physician, which takes a whole lot of pressure off of me to do family doctoring, and puts my mind at ease. I've only personally contacted him once when my dad had a prolonged time of vague fatigue and body aches. I try not to use the "I'm a doctor, so I am second-guessing you" card that I've had some patients' children pull. I called his doctor more as a son who wanted a clear story about what was going on than as a physician with thoughts on the situation.

"I first want to say that I am very grateful my parents have gotten such good care from you," I said at the start of the conversation. "It's nice to not have to wonder if they are getting good care."

He was very grateful. I would be if someone said that to me, and I really meant it.

"About his current situation," I continued, I don't want to sound like one of those meddling doctor children who want to second-guess their parent's doctor...."

I went on to discuss what has been done, adding some things that had occurred to me, specifically of a condition called polymyalgia rheumatica, which I see with some regularity in my office. He listened to me, and I made sure he knew that he had no extra obligation to listen to my thoughts because I am a doctor. We finished the conversation with a few more jokes and I hung up with increased confidence as well as gratefulness that my parents had very good medical care.

A few weeks, after my suggested diagnosis came to be true, my dad informed me that his doctor told him, "your son made the diagnosis; he deserves the credit." I earned major points from my parents on that one, but their doctor clearly got high score in my book.

My wife's parents haven't been as fortunate with a primary care physician. Their care has been done a la carte - only when they had problems, and that done with very little explanation. Being from the generation that doesn't question their doctor or demand explanations, the extended family was largely in the dark about their medical care. This meant that my brother-in-law (an internist) and I ended up having to figure out, suggest, and occasionally meddle to get them the care we thought was appropriate.

A few hospitalizations over the past few years and some mystery medical diagnoses brought the situation to crisis earlier this year. When we went to visit them in the spring, I was given a charge from the family: find them a good primary care doctor. Given that I am in Georgia and they are in Oklahoma, this was not the easiest task. I got some names from a fellow blogger (thanks, John), but the best lead was that of a physician who doesn't accept insurance, charging an hourly rate that made me gasp. It didn't seem to be a good match, as my in-laws wouldn't be thrilled to pay $200 for a viral illness.

Out of leads, I went to the only other source I could think of: Google. My search quickly led me to physician rating sites. I had recently hired a roofer and plumber via Angie's list (with good results on the roofer, and bad on the plumber - as I previously mentioned), so this seemed worth trying. One doctor seemed good, but his Med School graduation year was in the 70's, so I doubted he'd be around long. Another physician seemed OK until I read some of the reviews by patients who complained of wait times and that they didn't feel listened to.

I eventually happened upon a physician with my training (Internal Medicine and Pediatric) who had trained at a good program and who was young, but not too young. There are very few who get through a med/peds training at a tough program who are not motivated and thorough. I called, and the office treated me very well, even though I didn't mention I was a physician (I wanted a true idea of the office's user-friendliness). I got her an appointment, sent my mother-in-law the information, and left it at that.

I was thrilled and relieved when I heard their opinion about their doctor. He had spent time with them, had listened to what they had to say, and made them feel like they were no longer in limbo. He would take care of her and figure out what is going on. That's a big deal for me, as I don't like having to do detective work and second-guess other doctors. I don't like doing it as a PCP for my own patients, much less as a dutifully son-in-law. Yes, this doctor too won major points in my book.

The jury is still out, as they have only had one visit, but everything points toward a winner. I find it interesting being on the other end of the transaction of finding a good doctor. In this circumstance I was a health care consumer looking for what I needed. The tools I used were the usual: personal recommendations, Google, physician rating sites, and a call to the office. I had a slight advantage knowing the quality of the program this physician trained at, but it was still took a fair bit of luck.

To both of these physicians, my parents' PCP in New York and my in-laws' new PCP in Oklahoma, I give my deepest thanks. I know how easy it is to cut corners, to get tired, and to be worn out by our system. I know that it's easier to not take the extra time to explain, making sure you are heard. I know that it's more profitable to see extra patients and spend less time with each of them. Thank you for doing the right thing.

And thanks for all of those points!

*Extra points to the first person to identify the sport for the scoreboard at the top of this post.

Sit down.
Really, sit down. Trust me, please. You are going to be shocked with the news I am going to give you and I don't want any contusions, closed head injuries, street riots, or revolutions taking place in South American countries on my conscience.

Pretty crazy, right? I am not sure if it was an accident, like the infinite monkeys typing on a keyboard producing the works of Shakespeare (they'd write all of the Harlequin romance novels too, by the way). They had to eventually do something right, something that really benefits people, makes my life better, and potentially cuts cost. The thing they got right? The Medicare preventive exam.

Up to a year ago, the only way I would ever get paid to see a Medicare patient was when they had a problem. If a person came in with the desire to keep from being sick, we would have to get a waiver signed and charge them full price. So at those visits we would fish for any problems to justify it as a disease-management visit or one for acute care. This meant that any prevention that I did perform on my Medicare patients had to be done on the side during problem-oriented visits. So the motivation to do prevention was dependent on the nature of the doc; if they are OCD, didn't care about getting home on time, or less concerned about getting paid, patients got better care, otherwise it was hit or miss.

Plus, the chart itself was often neglected. Any time a doctor took to make the chart accurate was time away from other patients or time away from home. This sounds petty, but it takes a large effort to keep things updated, and with the low reimbursement of primary care, only those things that were grossly inaccurate got corrected in most patients' records. I was never given the time to make sure the records were accurate.

In January of 2011 this all changed (at least for Medicare patients). The Medicare Preventive Care Visit came into effect, paying well for keeping people well. The visit follows a specific structure (and arduous documentation, of course), and making the proper templates on our EMR and getting them to put out a suitable handout at the end of the visit took a lot of effort. But the effort paid off; my patients are very happy with these visits and I am able to do some things I have never had time for. The end result is this:

The patients are given their problem, medication, and allergy lists prior to the visit and correct them for us.

We can compile the names of other physicians they are visiting and make sure they are accurate.

We do a functional assessment on people, identifying those at risk for falls or those in bad home environments.

We screen for depression.

I get to discuss advance directives with people (living will and health power of attorney). This is probably the biggest change, as I rarely had the chance to talk about this before (and felt very guilty about it). In the past year I have talked to hundreds of people about this, and have probably saved a whole lot of trouble down the line because of it.

I check when their last screening tests (colonoscopy, mammogram, bone density) and get a copy of them when they aren't in my records (which is distressingly common). I order tests that are due and discuss with the patient when the next screening test is due.

More of my patients are getting pneumonia shots (pneumovax), and many more are getting the option to get the shingles vaccine (Zostavax).

In the end, the patient gets a handout (see below) that gives a road map of their care: what was done in the past and when, what was done today, and when things are due in the future. In short, the patient suddenly knows where they stand regarding their health, something that was not common prior to this.

I am actually being paid well enough for these visits to motivate me to schedule them on as many patients as possible. Certainly, the improvement to the chart itself and to the overall care of the patient is also motivation, but it's nice to be paid for doing good from time to time.

There are (of course) some negatives, including:

The document created in the chart is enormously wordy and not really useful on its own. Again, since we are paid for documentation, we get exactly that: lots and lots of words to justify our pay. This isn't too hard if you own a gibberish generator.

Some of the local GYN groups are billing for a Medicare preventive visit (although I seriously doubt they are meeting the cumbersome documentation guidelines), so some of our patients' bills are not paid for. We do our best to filter patients who may be in this situation, but some still get through. I cringe at the thought of these GYN's charts being audited.

Some patients try to get a disease management visit rolled into the preventive visits. They don't understand at first why I can't talk much about their diabetes on this visit, but when they get the finished product they are almost always satisfied.

Here is the 1st page of the handout given to the patient:

It's not bad. There are still some bugs being worked out, but it is very satisfying to have time to make sure the records are right and to have a significant percentage of my patients with up-to-date preventive care. This is very much like the GPS device I mentioned in an earlier post.

I am a little anxious about posting this, as it may encourage the government to double the number of monkeys on typewriters (i.e. bureaucrats) and so negate any good that comes of this. Anyhow, some of the monkeys are already busy running for president. But for now, I say something I rarely get to say:

A mother brought her infant for a well-baby visit, and my heart leaped. Last I heard, she had such bad postpartum heart failure that the word "transplant" was being mentioned. Her heart "ejection fraction" (how well her heart was pumping) was reported as an impossibly low number - one not generally associated with being out of the hospital, much less bringing your child to the pediatrician.

She was standing up, holding her baby when I entered the room. She smiled at me and I grinned back. She knew I knew the significance of that.

"You look wonderful," I said, broadening my smile.

She looked up from her baby with a tear barely appearing in her eye. "Thanks."

Nothing more had to be said. We both left with hearts lifted.

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I got an urgent call from a radiologist earlier in the week. One of my patients had a very high "calcium score" on a CT scan of the heart - meaning that there was a large amount of atherosclerosis (plaque) in her coronary arteries. It was unexpected, as the patient was moderate risk and had generally been in good shape. "There's a large deposit in the LAD," said the worried radiologist. My heart sank. I had to call the patient and explain this unexpected bad news to her.

I called, trying to emphasize the importance and seriousness of the finding without getting her overly panicked. "This is exactly why I ordered the test," I explained calmly, belying my pounding heart. "It's far better to be surprised in this way than to learn about it in the emergency room."

This seemed to help her, but the tone of my voice clearly had her worried. She asked me if she needed to do anything different. I told her to take aspirin, and then, pausing, said, "You might also want to take it easy until I can get you into a cardiologist. Maybe you shouldn't go jogging for now."

There was silence. I had just sent a message that this was not "no big deal," it was serious. I debated about saying it, since she had undoubtedly been living with this plaque build-up for a long time. Things were no different in her body today than they had been yesterday. But things were totally different.

I told her that I would make sure she got in to see the cardiologist as soon as possible. I hate it when people have to wait with a potentially deadly diagnosis looming. I hate to leave people hanging.

"Thank you. Thanks so much for calling," she said, sounding sincerely grateful I took the time to call.

I smiled to myself. When you drop a bomb on someone's life, the last thing you expect is gratitude. I sighed and my heart rate slowed down. "No problem," I responded. "I'm just glad we found this before it caused any trouble."

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I also saw Collin's mother this week. Collin is a boy with Asperger's syndrome (mild autism) who has my heart wrapped around his little finger. He is as sweet as a boy can be, with huge eyes, a sing-song way of speaking, and an innocence in outlook that leaves my heart longing for something I once had but lost.

He also is the head of my fan club. Every time I see his name on the schedule, my heart skips a few beats. I know I will be met with those huge eyes, that sweet voice, a hug around my waist, and lots of laughs as I playfully banter with him. His mother sits across the room and smiles, knowing just how incredibly sweet he is and happy to see him pouring that sweetness out on me. I should probably install a button in my office that I can press to have Collin added to the end of my schedule when I have a particularly bad day. Walking into the room to see him evaporates any stress I carry, heals any aches in my heart, and cures any self-pity I hide. He heals me.

His mother was seeing me today, however, and Collin wasn't there with him.

"I had to hide the fact that I had this visit from him," she explained. "He needs to go to school, and he would have been hard to get out the door if I gave him time to think about it."

I laughed. "He's about the sweetest kid I know."

"Yeah," she replied, not hiding the pride in her voice, "he sure is. When I finally told him this morning, he said 'Mom! You mean you are going to see Dr. Lamberts without me??'"

I shook my head. "Yeah, he's really got something for me. I am always thrilled when his name comes up on my schedule."

"You've got a special place in his heart, that's for sure." She said, her pride growing in her expression. "After I told him, he went to his room and then came back to me and said, 'Mom! Why didn't you tell me sooner? You didn't give me enough time to draw a picture for him!'"

I have a split medical personality. On one hand, I am a pediatrician; I light up around babies and love to mess around with little kids. On the other hand, I am an Internist; I love complex problems and love talking to the elderly. But the one part of internal medicine which gives me perhaps the most joy is the opportunity to solve medical puzzles. Yes, pediatrics has puzzles in it too, but they are far more common in adults.

The term used for a medical puzzle-solver is diagnostician. It is always a great compliment to a physician to be called a great diagnostician. It means you are a good thinker, have a good store of facts, know how to organize your thoughts properly, and can see patterns in things you otherwise would never have found. It is the Sherlock Holmes, Lord Peter Whimsey, or Harry Dresden side of medicine. The diagnostician searches for clues, but especially searches where they are most often missed: right out in the open.

I am not sure anyone has called me a good diagnostician, but there are few things that give as much satisfaction in my job. It calls on my creativity, my memory, my mental organization, my ability to ask questions, my power of observation, and my ability to put all the disparate pieces together to form a cohesive whole. It's not just coming up with an answer; it's coming up with a plan.

This is also one of the sides of medicine that makes it mentally taxing. The simplest sounding problem may be something much more in disguise. "My baby has a fever" may mean nothing, or it may be Kawasaki's disease or meningitis. "I have a cough" may be bronchitis (wink-wink), it may be lung cancer, or it may be the blood pressure pill someone was given a month ago. The important thing in approaching all of these patients is to do so with a process that is as consistent as possible. I try to go through every complaint, no matter how minor, using the same process. It's always tempting to jump ahead and speed things along, but that is where the worst mistakes are made.

Here is the process I use when approaching a patient with a problem they want solved:

Listen - I have to listen to what the patient says. How long has it gone on? What does it feel like? How long does it last? I have to pay attention to the details. Sometimes they will give the answer without knowing it, like when people say they've been tired for the past six months and then say that the neurologist started them on a medication, or that their mother died six months ago.

Direct the dialog - it's not just about asking the right questions, it is keeping the patient on track. Often they come in saying "I have a sinus infection," or "It's an asthma flare-up again." I don't let the patients pull me to conclusions for which I don't have enough evidence. I re-direct them, asking them to only tell me facts about what they experienced. I want to hear the story as best as they remember it, asking questions to get out the things I think are most important.

Believe the patient - Nothing makes doctors look worse than when we ignore what the patient says. I don't accept the patient's self-diagnosis, but not because I think they are lying to me; I just want to hear the story and see if I come to that conclusion as well. Patients are often very self-conscious about the story because it "sounds crazy", "doesn't make sense," or because they don't really remember things and think they will get it wrong. I do realize that people will get things wrong when they describe them, but that's where my questions come in. I ask enough questions, clarifying where they are not quite sure and repeating things to make sure I heard it right. It's OK that pain is hard to describe - it often is. I have no better source than the patient for the facts about what they experienced.

Examine - The physical exam is just part of the data gathering put into the context of the story the patient tells. It is sometimes the tipping point, but it is the whole story in which the answer lies. A heart murmur means different things in a child, a pregnant woman, a man with acute chest pain, and an elderly woman with shortness of breath. The exam should be thorough, but also should be directed by the story. I examine people to get more puzzle pieces.

Get more data - Family members are often helpful to give another perspective on things. Sometimes the patient has to come back several times before they remember a critical fact, or I ask the right question. I have to remember that sometimes at the first part of a movie or book, things seem confusing and contradictory, only to clarify as time passes and more facts are uncovered.

Make a list - this is actually something I do through the whole process, and is one of the big factors separating good clinicians from bad ones. The list, known as the differential, has two parts: 1) What are the things that I must rule out? What is the worst thing this could be? and 2) What are all of the other possible things this could be? The differential takes imagination and relies on the diagnostician's knowledge base of medicine the most. I usually don't make a physical list, but I always make the mental list when listening to patients. Sometimes I can rule out serious problems just by hearing the story, but sometimes they require more testing.

Address the fear - It's very important for clinicians to remember that patients are often afraid. If they come to the office with headache, they are often wondering if they have a brain tumor or aneurysm. If they have chest pain, they wonder if it's their heart. It's not just good medicine to ask the question, "what are they afraid of?", as the patient may be correct, it's the key to the patient's satisfaction with the care they get. It's often that fear that caused them to come to the office in the first place. A person with arm pain may actually wonder if they are having a heart attack, as arm pain goes along with angina sometimes. It's also important to know when the patient doesn't have fear; they just need an excuse for work or school.

Order the right tests - More is not better in this case. I don't like confusing the issue by ordering unnecessary tests. A person with a bright red throat, a sandpaper-like rash, and a fever of 104 does not need a strep test. Getting one will either show what I already know, or I will ignore it because it contradicts all of the other facts. This is where the differential list comes in: I only order tests that will rule-out important bad diagnoses or strengthen the case for others. But tests are not meant to change what I know, they are meant to change what I do. I don't order an MRI on everyone with sciatic nerve pain. That test is used for deciding if someone needs surgery or not. The best test for sciatica is to treat the presumed diagnosis with steroid and perhaps physical therapy. Those people who don't respond to these treatments are the ones who might need an MRI.

Look for patterns - It's often the pattern that makes the diagnosis, not the symptom. Headaches that are episodic - that come on for a period of time and go away completely - are likely to be migraines. Symptoms like shortness of breath, chest pain, or arm/neck pain which happen when the person exerts themselves and goes away only with rest are suggestive of heart disease. Chest pain that lasts for a few seconds and then goes away, however, is almost never a serious heart problem. This is where the experience of the clinician is the most important, as well as their ability to get a good story from the patient.

When all else fails, do nothing - As I said before, the diagnosis sometimes has to unfold over time. Doing nothing and watching to see what happens is very often the best thing (as long as serious problems are adequately ruled-out). If the mystery symptoms go away, then who cares what it was? Patients are usually OK with doing nothing if their fears are addressed, they feel that they've been listened to, they get a good enough explanation of the plan, and they have adequate follow-up. In other words, patients actually cooperate with doctors who communicate.

Gosh, this turned out to be longer than I expected. I really do love the detective portion of my job. I get to use my creativity and communication skills, and I get to comfort the anxious, answer questions, and sometimes uncover problems before they get serious.

Let me end with a bit of advice for patients:

Tell your story first. If you have theories, tell them only after you've told the story, otherwise you may cause the doc to jump to conclusions.

Don't be ashamed if it sounds silly. You feel what you feel, and sometimes the strangest symptoms are the key to the diagnosis.

Say why you came to be seen. What is the worst symptom and what do you fear the most?

Don't insist on tests or medications. More is often less. The best doctors, in my opinion, order less tests and give less medication than the worst ones.

Get a plan. Understand what the plan of action is, and when you should call or come back in.

Don't ever assume. If you don't get results, never ever ever ever assume "no news is good news." Never. You got that? Never.

Try not to be an interesting patient. It's bad when you are a puzzle to your doctor. Words like, "man, that's interesting," or, "I've never seen anything like this before," are usually bad signs. It's even worse when you are presented in front of a group of doctors or are published in a journal. Don't seek fame in this way. Stay boring.

I said I would do it and I will follow through with it: I am going to talk about good things about my job. I must confess, however, that finding 53 of them might be difficult at this moment, as I am overwhelmed with the craziness and stupidity of the system. I must also confess that I can't find a whole lot of good things to say about our system. I fight the system and it's foibles all day long, and try to practice good medicine despite the way I am forced to do it; so finding good stuff about the structure of our payment system will be difficult, if not impossible. Maybe it's just me and my current mindset. I hope so. Unfortunately, it is how good the good is that makes the bad all the worse. The fact that the system itself stands in the way of the good in medicine makes the system all the more broken.
Anyhow, I do have things that I really, really like about medicine. I've got to have them, as I could not deal with these negatives if I didn't have a reason to stay that was at least as strong as my reason to leave. It's like the nucleus of an atom: we know that the forces holding the protons together is strong, because they repellant force of two positively charged particles is very strong. There must be a stronger force keeping them together. Likewise, I am drawn to medicine in a very strong way, and nothing draws me back more than the exam room.

No, I am not talking about the table that is too high for my old people to climb on, out-of-date magazines, or the smell of rubbing alcohol. I am talking about the interchange I get to have every day with people. To me, the exam room encounter is medicine. It is the Holy of Holies, the sacred part of a secular system. The practice of medicine can be boiled down to a single thing: the interchange between a person with a need and a person who tries to meet that need. While this is actually the description of all commerce and much of human interaction, it is the nature of the interchange and needs that make it so special to me. Here are the things that make this encounter so unique and so (in my mind) sacred:

A. It is Personal

The patient does not need an object or a luxury item. They don't want to be entertained. The thing the patients need is themselves. They want to live and to be healthy. They want to have a good life and to be out of pain. Our possessions are not what define us, but to a large degree, our bodies do. We are what is confined in that package of flesh. Our time on earth is defined by what that body does, and how long it does it. So, to come asking for care for our bodies is intimately personal - a fact unfortunately forgotten by many in health care.

B. It is Private

The door to the exam room is closed and I am committed to keeping what goes on in the room closed off to others. The more that I can assure the patient that their privacy is safe, the more they will expose their needs to me. We humans don't like to share our needs with many people, as it exposes our weakness and vulnerability. We also feel that we are intruding on others' lives when we ask them for help. So, actually asking for help is only possible when done in a situation of great trust.

The fact that people can be asked to get naked in the exam room is evidence to the degree of vulnerability they are exposing to me. The nakedness extends to the emotional realm, as boundaries that are expected on the outside are not present behind the closed door.

C. It is Relational

The thing that is so sacred about the exam room to me is not the fact that it's private or personal, however; it is that I am asked to be with them in that vulnerable moment and hear the weaknesses. The relationship is physical: I listen to what they say, look at what they are, and feel their bodies with my hands. It is mental: I listen to them, think about them, and help them decide what to do. It is emotional: I hear their sadness, fear, and relief; I feel emotion as I hear their emotions; I try to help, heal, or comfort them. This is the sacred, as it is human relations stripped to the core, free from most of the pretense and facades that are there in nearly every other place.

D. It is Meaningful

I take great comfort in the fact that what I do has meaning. When other parts of my life are difficult, I find refuge in the opportunity I have every day. When I am feeling sad or anxious about other things, feeling insecure in my relationships or in my future, or regretting my decisions, I heal myself in the exam room. It's not that I see that my life is good compared to my patients - that's no comfort at all - it's that I get to do and to give to other people; and while I can lose relationships and material things, nobody can take away the good I have done.

It's really an honor to be a part of the exam room encounter every day. It does take its toll on my emotions, and it is a convenient escape when I'm avoiding other areas of my life, but I know it's where I need to be. I am glad that I am a doctor. I really lucked into the profession I chose, as I didn't know most of the good things before I enrolled in medical school. It's good for me to remember this good, as I can get lost in the struggles and troubles that the other part of my job brings. Our system needs to do everything it can to enable more real exam room encounters, and remind health care providers that they do more than just work at their jobs; they heal.